Wales is not alone in the challenges it faces in providing consistent and high quality healthcare. Organisations across the world wrestle with a common set of challenges; we know that demand for healthcare services is increasing globally, primarily due to population ageing, increased prevalence of chronic and complex health conditions, with a growing level of patient expectation.
Life expectancy in many countries is rising, an ageing population presents health and care systems with the challenge of balancing increasing demand with reduced expenditure. Governments worldwide are being expected to do more with less, which is unsustainable and must change to meet future demand.
The success of science, technology and medicine has driven unparalleled advances in our understanding of disease, disability and dying, resulting in increased life expectancy, but sometimes a greater period spent in poor health. Whilst our understanding has increased we still often fail to address the basic, ever increasing inequalities which occur and the unfair impacts that society can have upon this.
The really striking feature of these challenges is their inter-relationship: solving one requires a solution to them all. ‘Prudent Healthcare’, which now underpins health policy in Wales, recognises this inter-dependence and seeks a system-wide approach to them all.
We need to ensure that care is directed to those with the greatest need, while establishing and maintaining an equal relationship with the health care service. Evidence where available, must always inform decisions and rising healthcare budgets should deliver the sort of benefits we really want. Unnecessary variation in practices and outcomes across Wales should be reduced, with unnecessary or even dangerous practices eliminated.
Also implicit in a Prudent approach to health and care is the need to redraw the relationship between citizen and the state, to ensure that professionals and the public can work together as more equal partners. Wales needs an environment where people are able to take responsibility to find better solutions that best fit their own health needs and empowered to gain greater control over their own lives.
While health policy in Wales is devolved to the National Assembly it still faces other familiar challenges, related to its demography, the impact of preventable chronic diseases, longstanding social inequality and rising costs of health care. Crucially, Wales as distinct from other parts of the UK NHS, enjoys one particular advantage: coherence.
In a relatively small nation, with all elements of healthcare provision marshalled by seven population-based Health Boards, supported by Public Health Wales and two specialist NHS Trusts this ‘whole system’ already in place gives a Prudent approach to health and care an opportunity to flourish.
The origins of Prudent Healthcare lie in a desire to respond to these common, interconnected challenges in a way that makes sense to people, re-defining the whole system and not just the presenting problems but finding solutions together. The Bevan Commission took the concept and engaged with others to develop a final set of Prudent Principles which were accepted by the then Health Minister and now define this Prudent approach.
Prudent Healthcare is now attracting much interest and debate both within Wales and beyond. Recently the Bevan Commission hosted a discussion event with Professor Don Berwick, from the Institute for Healthcare Improvement and an international Bevan Commissioner. “In America we are almost addicted to overuse of healthcare services, however Wales is a small country, flexible and ready to make real change with a Prudent approach”.
Many complain that there is no time, yet they don’t stop doing things that are known not to work or abandon processes that create considerable unnecessary additional burden, without any health benefit. Often unnecessary interventions, appointments, processes and administration can be seen in practice which are of no use to professionals, the patient or the public. Understanding why this is done is complex, but ways are needed to address these issues and change in order to survive and thrive in Wales.
Doing nothing is not an option. To achieve the transformational change needed, a common vision must be shared to deliver sustainable services and the necessary skills for the future. A better balance between accountability, trust and risk is an essential part of a new NHS culture.
This is everyone’s responsibility, including those working in the system, those trained by the system, those using the system and the citizens whose taxes pay for the system. Above all it must be ensured that the people of Wales are proud, informed supporters and the true co owners of the NHS.
What does appear clear is that the many elements of current health and social care are neither desirable nor sustainable. Professionals and increasingly patients see Prudent Healthcare as the obvious choice and as Professor Sir Mansel Aylward Chair of the Bevan Commission challenges ‘who would want imprudence?’
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